Gallstone ileus, clinical presentation, diagnostic and treatment approach

Laparoscopic surgery for gallstone ileus

We present a case of a woman in her 70s who arrived in the emergency department with signs of small-bowel obstruction. CT scanning revealed acute cholecystitis with a cholecystoduodenal fistula, pneumobilia and small-bowel obstruction possibly secondary to gallstone ileus although no radio-opaque gallstones were seen. The patient underwent an emergency operation and intra-operative findings revealed mechanical small-bowel obstruction of the proximal jejunum where a 4×2 x 3 cm gallstone was impacted. A laparoscopic-assisted enterotomy was performed with stone extraction and primary closure. The patient made a full recovery. A planned laparoscopic cholecystectomy and repair of cholecystoduodenal fistula is scheduled on elective basis.

Gallstone Ileus as an Occult Cause of Small Bowel Obstruction and Subsequent Large Bowel Obstruction: A Report of a Rare Case

Gallstone ileus, a rare cause of mechanical bowel obstruction, occurs due to the formation of a cholecystenteric fistula allowing gallstones to migrate into the gastrointestinal tract. The condition occurs mostly in elderly patients, particularly women, and carries a significant mortality risk due to delayed diagnosis. This case report discusses a 77-year-old female patient with a history of chronic medical conditions, who self-presented with periumbilical pain, nausea, and reduced bowel movements. Initial imaging revealed pneumobilia and small bowel obstruction, leading to a diagnosis of partial obstruction attributed to adhesions. Despite surgical intervention and temporary symptom relief, the patient's condition deteriorated due to a subsequent colonic obstruction. The case was complicated by delayed recognition of gallstone ileus, as imaging initially misinterpreted the obstructive mass as a "stool ball" rather than a gallstone. Following diagnostic laparoscopy and subsequent exploratory surgeries, the patient was found to have a gallstone impacted in the rectum, leading to colonic ischemia and perforation. This resulted in progressive renal failure, respiratory failure, and ultimately, the patient's death in hospice care. This case underscores the diagnostic challenges of gallstone ileus and highlights two key delays: misattribution of obstructive symptoms to adhesions and failure to recognize colonic obstruction due to gallstone ileus. Early use of contrast-enhanced imaging and a high index of suspicion are crucial for timely diagnosis. This case emphasizes the importance of thorough inspection of the small bowel and ileocecal region during laparoscopy and the need for careful evaluation of imaging findings to improve patient outcomes in gallstone ileus cases.

Management of Gallstone Disease

Gallstone disease has plagued humanity since antiquity. Its recognition and treatment has been refined through decades as surgical technique and imaging capabilities have advanced. With the rise of the obesity epidemic and metabolic syndrome, its prevalence is also increasing. This review provides an overview of the various manifestations of gallstone disease and treatment modalities appropriate for its resolution.

A little goes a long way: A comparison of enterolithotomy versus single-stage cholecystectomy in the management of gallstone ileus

INTRODUCTION

Gallstone ileus is an infrequent complication of cholelithiasis with no specific guidelines for its management. This study aims to compare the outcomes of patients with gallstone ileus managed with both enterolithotomy with cholecystectomy (EL-CCY) versus those managed with enterolithotomy (EL) only.

METHODS

In this retrospective analysis of 2011–2017 Nationwide Readmissions Database, all patients with an index admission diagnosis of gallstone ileus were included. Patients were stratified based on the type of intervention received for gallstone ileus into those who underwent EL-CCY and those who underwent EL alone and compared. Primary outcomes were in-hospital complications (surgical site infections, sepsis, pneumonia, cardiac arrest, deep vein thrombosis, intestinal obstruction) and mortality. Secondary outcomes were hospital length of stay, hospital costs, and readmissions rate and cause of readmissions. Multivariable logistic regression analysis was performed.

RESULTS

A total of 1,960 patients were identified. The mean age was 67 years and 67% were female. Two hundred eighty-nine patients (14.7%) were managed with EL-CCY, whereas 1,671 patients (85.3%) underwent EL only. Overall, the readmission rate was 4.8%, whereas mortality was 4.2%. There was no significant difference between groups in terms of index-admission complications (24.8% vs. 21.7%, p = 0.415), mortality (6.2% vs. 3.9%, p = 0.068), rates of readmission (3.5% vs. 5.1%, p = 0.22), and cause of readmission (p > 0.05). Enterolithotomy and cholecystectomy group had significantly longer hospital length of stay (10 vs. 8 days, p < 0.001) and median hospital costs ($70,959 vs. $52,147, p < 0.001). On multivariable logistic regression analysis, female sex was a predictor of undergoing EL-CCY, whereas increasing age and higher grade of all-patient redefined diagnosis-related groups risk of mortality were independently associated with lower odds of undergoing EL-CCY.

CONCLUSION

Our findings suggest no difference between EL compared with EL-CCY in terms of complications, readmissions, and mortality. However, patients managed with EL-CCY had a longer hospital stay and higher hospital costs compared with EL. Further prospective studies are needed to validate these findings and develop management protocols for gallstone ileus.

LEVEL OF EVIDENCE

Therapeutic/Care Management; Level III.

Chronic Gallstone Ileus Presenting as Acute Small Bowel Obstruction: A Case Study

BACKGROUND Gallstone ileus is an uncommon cause of intestinal obstruction. Rigler's classic triad for a gallstone ileus includes the following: small bowel obstruction, air in the biliary tract, and an obstructing gallstone. This triad, however, is not always observed. We present an unusual case of a gallstone present in the small bowel for several years prior to presenting with an acute obstruction. CASE REPORT A 71-year-old man presented with 3 days of lower abdominal pain, constipation, and abdominal distension, with his last reported bowel movement 3 days prior. The patient's vitals were stable, with a white blood cell count of 11.47×10⁹/L and no lactic acidosis. Abdominal exam was significant for bilateral lower-quadrant tenderness and mild distension. Findings on abdominal computed tomography revealed a large foreign body in the distal small bowel, with evidence of proximal small bowel obstruction. Review of imaging from 4 years prior incidentally revealed the foreign body more proximally in the jejunum. Laparoscopy and enterotomy were performed with removal of a 4×4 cm gallstone encased in fecal material. The patient recovered well from surgery and had no complications. CONCLUSIONS A 71-year-old man presented with lower abdominal pain and distension. Work-up revealed a small bowel obstruction secondary to a presumed foreign body, later found to be a gallstone. We present a highly unusual presentation of a gallstone ileus, with radiographic evidence of an enteric gallstone present 4 years prior, with no evidence of pneumobilia or biliary-enteric fistula in current or previous computed tomography scans.

Laparoscopic-Assisted Enterolithotomy for Recurrent Gallstone Ileus: A Case Report

Gallstone ileus is the mechanical obstruction of the bowel due to gallstone impaction. It forms when a fistula is created between the gallbladder and the gastrointestinal tract, which can result in small bowel obstruction. Its surgical management ranges from enterolithotomy, cholecystectomy, and fistula closure performed together (one-stage) or performed separately (two-stage), while some patients undergo simple enterolithotomy. Emergency surgery with open enterolithotomy, with or without biliary tract surgery, has been replaced by laparoscopic-assisted enterolithotomy as a safer and more rapid procedure. This report is of a 68-year-old woman treated with laparoscopic-assisted enterolithotomy for gallstone ileus which recurred. A 68-year-old woman with type 2 diabetes mellitus, hypertension, breast cancer, and end-stage renal disease on hemodialysis presented with a gallstone ileus and was surgically managed with successful laparoscopic-assisted enterolithotomy. Seven days after the initial surgery, she again presented with gallstone ileus requiring reoperation. A repeat laparoscopic-assisted enterolithotomy was performed with no complications and full resolution of her symptoms. Operative management of gallstone ileus and subsequent recurrence continues to be highly debated. With no randomized studies and limited data, there is no current gold standard surgical procedure for either setting. Simple laparoscopic-assisted enterolithotomy is the favored surgical technique as it is associated with decreased morbidity, mortality, operative time, and complications. This report demonstrates that a CT scan is crucial in differentiating recurrent gallstone ileus from postoperative ileus, with a repeat laparoscopic-assisted enterolithotomy providing a safe and effective treatment option. Moreover, patient follow up is essential for monitoring symptom resolution.

What are the clues to gallstone ileus when stones don't show up on scans? A case presentation and literature review

Gallstone ileus is a rare yet significant cause of mechanical bowel obstruction, particularly in elderly patients. This condition arises when gallstones migrate into the gastrointestinal tract through a cholecystoenteric fistula, often due to chronic inflammation. Despite medical advancements, gallstone ileus remains associated with high morbidity and mortality rates due to delayed diagnosis and nonspecific symptoms. The clinical presentation typically includes intermittent nausea, vomiting, abdominal pain, and constipation, which can obscure the diagnosis. Advanced imaging techniques, especially computed tomography (CT), are crucial for identifying key diagnostic features such as pneumobilia, ectopic gallstones, and signs of bowel obstruction. Gallstone ileus should be considered in any case of small bowel obstruction, even if CT imaging is inconclusive, as gallstones can be radiolucent. Indirect clues like pneumobilia and dilated small bowel loops can lead to the diagnosis. Effective management of gallstone ileus requires prompt surgical intervention to remove the obstructing gallstone and restore bowel patency. The primary surgical procedure is enterolithotomy, although additional procedures such as cholecystectomy and fistula repair may be necessary depending on the patient's condition and intraoperative findings. The choice of surgical approach should be individualized, considering the patient's overall health and the specific characteristics of the obstruction. Early recognition and timely surgical management are essential to prevent complications and improve patient outcomes.

Small bowel obstruction secondary to gallstone ileus: An unusual presentation of cholelithiasis

INTRODUCTION AND IMPORTANCE

Gallstone ileus remain a rare but significant cause of small bowel obstruction, especially in the elderly population. It is associated with high mortality due to nonspecific symptoms and delayed diagnosis.

CASE PRESENTATION

A 69-year-old male with a history of cholelithiasis presented with symptoms and signs suggestive of small bowel obstruction. Computed tomography (CT) scan showed pneumobilia, and small bowel obstruction, suggestive of gallstone ileus. Initial management involved exploratory laparotomy with enterotomy and gallstone removal followed by cholecystectomy and fistula closure three months later.

CLINICAL DISCUSSION

Gallstone ileus results from large gallstones causing mechanical intestinal obstruction, often via a cholecysto-intestinal fistula. CT scans are crucial for diagnosis, with surgical options for better patients' outcomes. Management of gallstone ileus involves removing the obstruction and repairing the cholecysto-intestinal fistula, but surgical approaches vary based on patient factors.

CONCLUSION

Surgeons should be aware of the variable clinical presentations and the rationale behind choosing either a one-stage or staged surgical approach, particularly in managing patients with fistulas or severe adhesions.

Unusual causes of Small bowel obstruction: a review of the literature and revisited cross-sectional imaging checklist

Intestinal obstruction is a common surgical emergency with high morbidity and mortality. Patients presenting with features of small bowel obstruction need urgent evaluation to avoid complications such as bowel gangrene, perforation, or peritonitis. Imaging is necessary in most cases of suspected bowel obstruction, to take an appropriate decision, for apt patient management. Among the common causes of small bowel obstruction, adhesions, external herniae, malignancies, and Crohn's disease top the chart. Imaging helps in determining the presence of obstruction, the severity of obstruction, transition point, cause of obstruction, and associated complications such as strangulation, bowel gangrene, and peritonitis. This review is based on the cases with unusual causes of bowel obstruction encountered during our routine practice and also on the extensive literature search through the standard textbooks and electronic databases. Through this review we want our readers to have sound knowledge of the imaging characteristics of the uncommon yet important causes of bowel obstruction. We have also revisited and structured a checklist to simplify the approach while reporting a suspected case of small bowel obstruction. Imaging plays a key role in the diagnosis of small bowel obstruction and in determining the cause and associated complications. Apart from the common causes of small bowel obstruction, we should also be aware of the uncommon causes of small bowel obstruction and their imaging characteristics to make an accurate diagnosis and for apt patient management.

Noncalcified Gallstone Ileus in Computed Tomography (CT) Abdomen and Pelvis With Contrast

Gallstone ileus is a rare but serious complication of chronic cholecystitis, causing mechanical small bowel obstruction. Contrast-enhanced computed tomography (CT) plays a key role in radiological diagnosis. The classic findings are known as Rigler's triad, comprised of pneumobilia, small bowel obstruction, and calcified gallstones. We report a unique case of a 74-year-old female patient who presented with hallmark clinical features of bowel obstruction. CT revealed bowel obstruction and pneumobilia but did not show calcified gallstones, deviating from the usual Rigler's triad. Following midline laparotomy, a noncalcified gallstone was confirmed causing bowel obstruction. This case underscores the need to consider gallstone ileus in small bowel obstruction even in rare cases where conventional CT findings are not present, alongside the value of comprehensive radiological analysis and maintaining a high degree of clinical suspicion. Timely recognition of such atypical cases is vital for effective surgical treatment and better patient outcomes.

Massive gastropathy due to gallstone obstruction of the duodenum (Bourveret syndrome)

Gallstones are common in the general population and are often asymptomatic, but they can also cause complications such as cholecystitis and pancreatitis. In rare instances, they can lead to the formation of a cholecystoduodenal fistula and gallstone ileus. Gastric dilatation and distension following gallstone ileus are extremely uncommon and have rarely been reported in the literature. We report a fatal case of massive gastropathy as a result of Bouveret syndrome secondary to gallstone obstruction.

Gallstone ileus: report of two cases and a mini literature review

Gallstone ileus is a relatively rare complication of cholelithiasis, and an uncommon cause of small bowel obstruction most commonly seen in elderly and debilitated people with associated comorbidities. Symptoms of gallstone ileus are insidious and may be vague while the delay in diagnosis results in a high mortality rate. Herein we report two cases of gallstone ileus in elderly patients with complex medical history who presented at the emergency department with abdominal pain and distension, vomiting and fluid/electrolyte disorders due to cholecysto-enteric fistula and bowel obstruction.

Acute cholangitis: a state-of-the-art review

Acute cholangitis is a potentially life-threatening bacterial infection of the intra and/or extrahepatic bile ducts. It remains the second and third cause of community-acquired and hospital-acquired bacteremia, respectively, and is associated with mortality rates of up to 15%, despite advances in broad-spectrum antimicrobial therapy and improved access to emergency biliary tract decompression procedures. Even though not much has changed in recent years in terms of diagnosis or treatment, new data have emerged regarding multidrug-resistant bacteria that serve as etiologic agents of cholangitis. Moreover, different approaches in antibiotic regimes depending on severity grading and bile sample cultures as well as novel minimally invasive endoscopic procedures that can help when consecrated treatments such as endoscopic retrograde cholangiopancreatography (ERCP) fail, cannot be performed, or are unavailable have been proposed. This state-of-the-art review aims to offer a complete and updated assessment of the epidemiology, novel diagnostic and therapeutic methods, complications, and prognostic variables of acute cholangitis. The authors will review the prognostic implications of unusual complications, the relevance of regular bile samples and antibiograms, and their new role in guiding antibiotic therapy and limiting antibiotic resistance to present an organized and comprehensive approach to the care of acute cholangitis.

Balancing Urgency and Strategy in the Surgical Management of a Complex Case of Gallstone Ileus: A Surgical-Video-Based Case Report of a 60-Year-Old Female

Gallstone ileus is an uncommon but potentially life-threatening complication of gallstone disease, characterized by the obstruction of the gastrointestinal tract by a gallstone, typically at the ileocecal valve. This condition predominantly affects elderly patients and carries a high risk of morbidity and mortality due to delayed diagnosis and the complexity of associated comorbidities. We report the case of a 60-year-old woman with a history of hypertension and cholelithiasis who presented with a four-day history of intermittent epigastric pain, nausea, vomiting, and an inability to pass stool or flatus. Initial imaging studies, including ultrasonography and computed tomography, revealed a biliary-enteric fistula with a large obstructing gallstone at the ileocecal valve. Despite conservative management with intravenous fluids, nasogastric tube suction, and antibiotics, the patient's symptoms persisted, necessitating surgical intervention. A midline laparotomy was performed, during which the gallstone was successfully removed via enterotomy. The patient recovered without complications and was discharged in stable condition. The complexity of management, particularly in elderly patients with multiple comorbidities, necessitates careful consideration between the one-stage and two-stage surgical approaches. In this case, the decision to perform an enterotomy without immediate cholecystectomy reflects a two-stage strategy, aimed at minimizing operative risk while addressing the immediate obstruction. This approach underscores the need for individualized management plans, where the choice between one-stage and two-stage surgery is guided by the patient's overall clinical status.

Bouveret syndrome preceding classical gallstone ileus: a rare presentation of a cholecystoduodenal fistula

Bouveret syndrome is the rarest variant of gallstone ileus characterized by the passage and impaction of a gallstone through a bilioenteric fistula leading to gastric outlet obstruction. The documented movement of an impacted gallstone in Bouveret syndrome through the gastrointestinal tract has not been previously discussed in the literature. A 64-year-old man presented with acute on chronic epigastric pain, fevers, and vomiting. Abdominal computed tomography established a diagnosis of Bouveret syndrome. A trial of endoscopic gallstone extraction was unsuccessful. Laparoscopic gastrotomy and stone removal were later attempted, however, intraoperatively it was noted that the stone had migrated and was now impacted in the jejunum causing a small bowel obstruction. The clinical picture was now that of gallstone ileus. Laparoscopic enterolithotomy was performed successfully. This article discusses the radiological, endoscopic, and intraoperative findings in this rare case of Bouveret syndrome that had evolved into classical gallstone ileus following stone migration.

An unusual case of gallstone ileus 35 years post-cholecystectomy masked by an incisional hernia

Gallstone ileus is an uncommon cause of mechanical bowel obstruction in patients with cholecystitis and gallstones who develop a fistula over time. In the post-cholecystectomy patient, the presence of gallstone ileus is extremely rare; these patients have different pathophysiological pathways, such as a spilled gallstone that subsequently erodes into the bowel, subtotal cholecystectomies, and diverticulae that can hold a gallstone for hidden several years. In these patients, the clinical presentations are unique because of their rarity and because the gallbladder had been previously removed. A high index of suspicion by the medical team is needed for diagnosis. We present the case of an 85-year-old male who had a history of cholecystectomy 35 years ago. He presented to the emergency department with intestinal obstruction. Since he had a hernia, it was thought to be the cause of the obstruction; however, during surgery, we were surprised to find a gallstone ileus. After surgery, he fully recovered.

Management of complex acute biliary disease for the general surgeon: A narrative review

Acute gallbladder diseases are a common surgical emergency faced by General Surgeons that can sometimes be quite challenging. These complex biliary diseases require multifaceted and expeditious care, optimized based on hospital facility and operating room (OR) resources and the expertise of the surgical team. Effective management of biliary emergencies requires two foundational principles: achieving source control while mitigating the risk of injury to the biliary tree and its blood supply. This review article highlights salient literature on seven complex biliary diseases: acute cholecystitis, cholangitis, Mirizzi syndrome, gallstone ileus with cholecystoenteric fistula, gallstone pancreatitis, gall bladder cancer, and post-cholecystectomy bile leak.

Gallstone ileus: An unusual complication of cholelithiasis in a 42-year-old female with no comorbidities

INTRODUCTION AND IMPORTANCE

Gallstone ileus is a rare condition, accounting for 0.5 % of mechanical small bowel obstructions. It is a misnomer for mechanical intestinal obstruction caused by one or more gallstones impacted within the gastrointestinal tract lumen, which occurs mostly in the elderly and female population. Treated usually by operative enterolithotomy. Preoperative diagnosis is challenging, but CT, which is investigation of choice, and magnetic resonance imaging (MRI) have made it easier to diagnose.

CASE PRESENTATION

A 42-year-old female presented to the emergency department with epigastric abdominal pain for 1 week, preceded by 2 months of RUQ pain. CT scan with contrast showed a classical finding of small bowel obstruction and ectopic gallstone. An emergency exploratory laparotomy, enterolithotomy, and cholecystectomy with fistula repair were performed in one surgical stage.

CLINICAL DISCUSSION

Laparoscopic enterolithotomy alone is the most preferred method due to its low incidence of complications but one-stage or two-stage surgeries are also options, but the choice between surgical modalities depends on the patient's status.

CONCLUSION

Gallstone ileus mostly affects older female patients who have a history of gallbladder disease and often have a poor prognosis that becomes worse with age and comorbidities. However, this was a young female patient with no comorbidities, which may affect the prognosis compared to those who are at risk for gallstone ileus.

Electrohydraulic lithotripsy treatment with mother-baby endoscopic system useful for gallstone impacted in ileum

Watch a video of this article.

Traveling gallstones: review of MR imaging and surgical pathology features of gallstone disease and its complications in the gallbladder and beyond

Gallstone-related disease comprises a spectrum of conditions resulting from biliary stone formation, leading to obstruction and inflammatory complications. These can significantly impact patient quality of life and carry high morbidity if not accurately detected. Appropriate imaging is essential for evaluating the extent of gallstone disease and assuring appropriate clinical management. Magnetic Resonance Imaging (MRI) techniques (including Magnetic Resonance Cholangiopancreatography (MRCP) are increasingly used for diagnosis of gallstone disease and its complications and provide high contrast resolution and facilitate tissue-level assessment of gallstone disease processes. In this review we seek to delve deep into the spectrum of MR imaging in diagnose of gallstone-related disease within the gallbladder and complications related to migration of the gallstones to the gall bladder neck or cystic duct, common hepatic duct or bile duct (choledocholithiasis) and beyond, including gallstone pancreatitis, gallstone ileus, Bouveret syndrome, and dropped gallstones, by offering key examples from our practice. Furthermore, we will specifically highlight the crucial role of MRI and MRCP for enhancing diagnostic accuracy and improving patient outcomes in gallstone-related disease and showcase relevant surgical pathology specimens of various gallstone related complications.

Bouveret's syndrome: An old diagnosis. A modern multimodality approach (endoscopic and robotic surgical) of gastric outlet obstruction: Report of two cases

INTRODUCTION AND IMPORTANCE

Bouveret's syndrome is an uncommon condition characterized by the impaction of a gallstone in the pylorus or duodenum via a cholecysto-enteric fistula causing gastric outlet obstruction. We report two unusual cases of Bouveret's syndrome causing gastric outlet obstruction in two elderly patients.

CASE PRESENTATION

Two elderly female patients presented to the surgical assessment unit with features of gastric outlet obstruction. In both cases, an urgent computed tomography (CT) of the abdomen showed pneumobilia, gastric distension, and gallstones impaction at the duodenal bulb. In Patient 1, endoscopic removal of the impacted gallstones was done successfully. She was discharged three days following an uneventful recovery. In Patient 2, an endoscopic removal of a single large gallstone was attempted, which was unsuccessful. She underwent robotic gastrotomy with extraction of the large gallstone with primary repair. She was discharged on 8th postoperative day.

CLINICAL DISCUSSION

Treatment options for Bouveret's syndrome include endoscopic management and surgery. The selection of treatment options depends upon factors like the degree of obstruction, the impaction site, number, type or size of gallstones, patient co-morbidities and clinical parameters at presentation, as well as expertise available, both endoscopic and surgical.

CONCLUSIONS

Bouveret's syndrome is one of the rare complications of gallstone. Endoscopic management can be effective at removing the impacted gallstones, which is particularly helpful for those elderly patients who have multiple medical co-morbidities, as in our first patient. Surgical management like minimal invasive surgery (robotic) can be beneficial in failed endoscopic attempt of removal of stone like in the second patient.

Incidentally Found Cholecystoduodenal Fistula and an Unusual Case of Gallstone Ileus After Laparoscopic Cholecystectomy

Gallstone ileus, a rare and potentially fatal complication of cholelithiasis, occurs when gallstones breach the gastrointestinal tract through a fistula, causing an obstruction and potentially leading to severe complications. This case report details the experience of a 44-year-old woman with gallstone ileus stemming from an unnoticed cholecystoduodenal fistula following a routine cholecystectomy. The fistula was only discovered during surgery despite advanced imaging, revealing extensive adhesions. The discovery led to a subtotal cholecystectomy and fistula repair. Postoperatively, complications arose, prompting a computed tomography scan to rule out further issues. However, she later returned with gallstone ileus, necessitating a second operation. This case underscores the importance of thorough intraoperative exploration for biliary enteric fistulas during cholecystectomy, potentially averting the need for subsequent interventions. The case also highlights the diagnostic challenges of gallstone ileus and the significance of clinical suspicion.

Endoscopic management of Bouveret syndrome with electrohydraulic lithotripsy

Video 1Endoscopic management of Bouveret syndrome with electrohydraulic lithotripsy.

Small intestinal obstruction due to a giant gallstone: a rare case report from Syria

Introduction and importance

Gallstone ileus is a rare and potentially life-threatening condition characterized by the obstruction of the small intestine due to a gallstone. It occurs as a complication of gallstone disease, where a large gallstone erodes through the gallbladder into the gastrointestinal tract, creating a fistula.

Case presentation

A type 2 diabetic woman in her 50s presented to the emergency department complaining of abdominal pain and vomiting. She has not emptied her bowels since 3 days ago. A clinical examination showed tenderness in the abdomen associated with fecal vomiting. A computed tomography (CT) scan was performed and showed a dilated gallbladder with gas. A giant gallstone in a small intestinal loop was observed. The diagnosis was a small intestinal obstruction due to a giant gallstone and a duodenal-biliary fistula.

Clinical discussion

Gallstone ileus is an occasional complication of cholelithiasis, occurring in less than 0.5% of patients. Gallstone ileus frequently occurs in the terminal ileum and the ileocecal valve. Regarding the clinical presentation, abdominal pain is the most common symptom, followed by vomiting and constipation. CT scan is the gold standard utilized to diagnose gallstone ileus. Surgical intervention is the mainstay treatment for giant gallstone ileus, with enterolithotomy being the most commonly performed procedure.

Conclusion

Gallstone ileus is an uncommon but potentially life-threatening condition that can emerge in elderly patients with a history of cholelithiasis. It is crucial for clinicians to maintain a high index of suspicion when encountering older patients with risk factors for cholelithiasis and intestinal obstruction.

Surgical management of gallstone ileus after one anastomosis gastric bypass: A case report

BACKGROUND

Gallstone ileus following one anastomosis gastric bypass (OAGB) is an exceptionally rare complication. The presented case report aims to highlight the unique occurrence of this condition and its surgical management. Understanding the clinical presentation, diagnostic challenges and successful surgical intervention in such cases is crucial for healthcare professionals involved in bariatric surgery.

CASE SUMMARY

We present a case report of gallstone ileus following OAGB and discuss its diagnosis and surgical management. A 66-year-old female with a history of OAGB presented to the emergency room with symptoms of small bowel obstruction. Computed tomography scan revealed a gallstone impacted in the distal ileum, causing obstruction. The patient underwent a laparoscopically assisted enterolithotomy, during which the gallstone was extracted and the enterotomy was closed. The patient had an uneventful recovery and was discharged on postoperative day four.

CONCLUSION

Gallstone ileus should be considered as a possible complication after OAGB, and prompt surgical intervention is usually required for its management. This case report contributes to the limited existing literature, providing insights into the management of this uncommon complication.

Gallstone Enteropathy: An Unusual Cause of Bowel Obstruction

Gallstones causing bowel obstruction, known as gallstone ileus, are rare and account for less than 0.5% of small bowel obstruction cases. Additionally, it is a rare complication affecting only 0.3% of patients who have gallstones. Fistula formation between the biliary system, most commonly between the gallbladder and duodenum because of their proximity, facilitates the migration of gallstones into the enteric system with subsequent impaction in the small intestine, usually in the distal ileum close to the ileocecal valve, promoting the development of mechanical small bowel obstruction. Computerized tomography of the abdomen and pelvis is a confirmatory and widely used imaging study when there are two signs of Rigler's triad, which includes pneumobilia, evidence of small bowel obstruction and the presence of radiopaque stones. We report a case of a 75-year-old Caucasian man who presented with abdominal distention with signs of severe dehydration secondary to intractable nausea and vomiting complicated with severe acute kidney injury and was found to have a 4.7-centimeter gallstone-induced small intestinal obstruction.

Mechanical Small Bowel Obstruction Due to Gallstone Ileus: Diagnostic Challenges and Surgical Management

Gallstone ileus is a true mechanical intestinal obstruction. It is caused by gallstone impaction in the gastrointestinal (GI) tract after eroding and passing through a bilioenteric fistula. Gallstones are frequently impacted in the terminal ileum. Computed tomography (CT) imaging is diagnostic and shows specific findings of dilated small bowel loops suggesting small bowel obstruction, pneumobilia, and impacted gallstone in the small bowel. Favorable outcome is achieved by having strong clinical suspicion, timely diagnosis, preoperative resuscitation, and early surgical intervention. The three available surgical procedures to relieve gallstone ileus are entrolithotomy alone; one-stage procedure of enterolithotomy, cholecystectomy, and fistula closure; or two-stage procedure of enterolithotomy followed by cholecystectomy. This article outlines the clinical presentation, diagnosis, resuscitation, and different surgical interventions of patients with gallstone ileus.

Colonic Perforation Secondary to Gallstone Impaction in the Sigmoid Colon

Introduction

Gallstone sigmoid ileus is a very rare manifestation of large bowel obstruction. Mainly, three conditions predispose the manifestation of the entity; in particular, an episode of cholecystitis causing cholecysto-colonic fistula; a large gallstone; and narrowing of the sigmoid colon secondary to diverticular disease or malignancy. Case Report. An 82-year-old man presented to the emergency department with a one-week history of severe constipation, tachypnoea, tachycardia, hypotension, and high lactate. Physical examination demonstrated cyanosed upper and lower extremities and palpation of the abdomen revealed signs of peritonism, abdominal distention, and guarding. Computerized tomography scan demonstrated perforation of the hollow viscus organ secondary to impaction of the large gallstone in the sigmoid colon. Laparotomy revealed sigmoid perforation and widespread feculent peritonitis. The patient underwent Hartmann's procedure. After the intervention gave concerns regarding the patient's haemodynamic stability, he was transferred to the intensive care unit. The patient passed away on the third postoperative day due to complications secondary to haemodynamic instability.

Conclusions

Patients with early diagnosed uncomplicated sigmoid gallstone ileus can be managed with endoscopic mechanical lithotripsy. In case of failure, open or laparoscopic enterolithotomy can be applied. However, when patients present with complications, surgery should not be delayed. In our case, Hartmann's procedure was an absolute indication due to sigmoid perforation and widespread feculent peritonitis.

Two Sites of Obstruction with Gallstones: A Case Report of Bouveret Syndrome with a Concurrent Biliary Ileus

Bouveret syndrome is a gastric outlet obstruction, and biliary ileus is an obstruction of the small bowel, and both are caused by a gallstone that escaped the gallbladder through a bilio-enteric fistula. The concurrent occurrence of obstruction at both sites is encountered very rarely, and only two such cases associated with Bouveret syndrome were reported before. We now present a case involving a 78-year-old female with simultaneous obstruction at both the duodenum and jejunum. The literature is reviewed to evaluate the incidence of such a situation and to discuss the management of the case.

An unusual case of gallstone ileus within the cecum and ascending colon: a case report

Gallstone ileus is a rare cause of intestinal obstruction. Due to long-standing inflammation of the gallbladder, fistulization can occur within nearby structures, most commonly to the duodenum or hepatic flexure of the colon. Through these fistulas, a stone can migrate and result in a small bowel obstruction or a large bowel obstruction. This case exemplifies the diagnosis and treatment of gallstone ileus, along with potential complications due to stone migration. Early recognition and treatment of gallstone ileus is important, as stone migration can lead to increased mortality with delayed diagnosis.

Radiological Diagnosis and Surgical Treatment of Gallstone Ileus

We report on the diagnosis and treatment of a patient who presented with a small bowel obstruction due to gallstone ileus. This condition is an infrequent complication of cholelithiasis that presents with non-specific and intermittent findings, including bloating, early satiety, constipation, nausea, and vomiting. Contrast-enhanced CT features the classic imaging finding, called Rigler's triad, which includes small bowel distension, gas in the gallbladder, and an ectopic gallstone. Laparoscopic enterolithotomy is employed to prevent further erosion through the gallbladder wall and into the adjacent gastrointestinal structures. The early diagnosis and treatment of gallstone ileus results in decreased morbidity and mortality.

Abdominal Pain and Hypotension in a 70-Year-Old Woman

A 70-year-old woman with hypertension, atrial fibrillation, congestive heart failure, and gallstones had 3 days of nausea, vomiting, and abdominal pain. Abdominal computed tomography showed a thickened gallbladder wall with intraluminal air adherent to the duodenum and a gallstone in the middle ileum with proximal bowel distension. What is the diagnosis and what would you do next?

Gallstone ileus: A case report and review of the literature

INTRODUCTION AND IMPORTANCE

Gallstone ileus (GI) is defined as the occlusion of the intestinal lumen due to the impaction of one or more gallstones. The optimal management of GI is not consensual. We report a rare case of GI with a successful surgical treatment for a 65 year-old-female.

CASE PRESENTATION

A 65 year-old-woman, presented with biliary colic pain and vomiting for three days. On examination, she had a distended tympanic abdomen. A computed tomography scan revealed signs of small bowel obstruction due to a jejunal gallstone. She had pneumobilia due to a cholecysto-duodenal fistula. We performed a midline laparotomy. We found a dilated and ischemic jejunum with false membranes regarding the migrated gallstone. We performed a jejunal resection with primary anastomosis. We performed cholecystectomy and closed the cholecysto-duodenal fistula at the same operative time. The postoperative course was uneventful.

CLINICAL DISCUSSION

We reported successful surgical treatment for GI. It was a one-step procedure. GI is a rare situation. Due to their restricted lumen, the terminal ileum and the ileocaecal valve are where GI occurs most commonly. GI appears usually in elderly patients with comorbidities. The clinical presentation is not specific. CT scan evokes the diagnosis with high specificity. The surgical management of GI is not consensual. In our case, we performed bowel resection due to the presence of an ischemic intestine.

CONCLUSION

GI is a rare situation. It appears usually in elderly patients with comorbidities. The clinical presentation is not specific. The surgical management of GI is not consensual.

Gallstone Ileus With Cholecystoenteric Fistula in an Elderly Female: A Case Report

Mechanical small-bowel obstruction can occur due to various reasons, including the impaction of a gallstone in the ileum after it has passed through a cholecystoenteric fistula. Gallstone ileus is an infrequent yet significant cause of this condition. This case report documents an instance of gallstone ileus, which accounts for less than 1% of patients with mechanical small bowel obstruction. We report a 75-year-old female patient who presented with colicky pain in both upper quadrants, hyporexia, and constipation that worsened during a period of nine days, which subsequently was accompanied by nausea and vomiting of bilious appearance in the next three days. Abdominal CT reported a dilated common bile duct (1.7 cm) with multiple stones inside measuring between 5 and 8 mm associated with pneumobilia of intrahepatic bile ducts and dilatation of small intestinal loops produced by a high-density image of approximately 2.5 cm. Laparoscopic exploration showed an obstructive mass measuring 15 cm from the ileocecal valve corresponding to a 2.54 x 2.35 cm gallstone, which was removed and enterorrhaphy was performed. The sine qua non condition for gallstone ileus to occur is the presence of a fistula between the gallbladder and the gastrointestinal tract. The treatment is mainly surgical and should be aimed primarily at the intestinal obstruction and secondarily at the cholecystoenteric fistula. This condition tends to have a high rate of complications and consequently long hospital stays. Making a timely diagnosis provides us with the tools for a surgical approach aimed at intestinal obstruction and subsequently in the management of the biliary fistula.

Bouveret syndrome: a rare complication of gallstone disease

A Caucasian man in his late 80s was admitted with central abdominal pain, abdominal distension and continuous vomiting, on the background of a recent admission for acute cholecystitis. The patient was managed for subacute bowel obstruction and was admitted to general surgery for further investigation. His blood tests showed raised inflammatory markers and deranged liver function tests. A CT scan showed the migration of a large gallstone, previously seen in the neck of the gallbladder on prior admission, to the proximal duodenum causing a degree of gastric outlet obstruction. A diagnosis of Bouveret syndrome was made, and although initially managed conservatively, the patient ultimately underwent surgery to remove the gallstone which had relocated again to the terminal ileum. Our case highlights the importance of considering rare complications such as Bouveret syndrome in patients presenting with bowel obstruction, particularly in the context of recent or chronic cholecystitis.

Synchronous Gallstone Ileus and Bouveret’s Syndrome: A Report of Two Rare Concurrent Complications of Gallstone Disease

Cholecystoenteric fistulas occur as a result of a chronic inflammatory insult involving the gallbladder and the erosion of both its wall and a bowel segment. When the fistula develops, it creates a pathway for gallstones to migrate and cause an intestinal obstruction, known as gallstone ileus. When it obstructs the gastric outlet, a proximal variant of gallstone ileus occurs, known as Bouveret's syndrome. A 65-year-old man presented to the emergency department with a three-day history of epigastric and right upper quadrant pain and persistent vomiting, preceded by unintentional weight loss of 15 kg over three months. Endoscopic and complementary imaging studies identified a concurrent gastric outlet obstruction caused by a lodged gallstone in the duodenal bulb and gallstone ileus. The patient underwent an urgent exploratory laparotomy and was submitted to an enterolithotomy and gastrolithotomy. Due to a sudden deterioration on the fourth postoperative day, he underwent an emergent re-laparotomy that found fecal peritonitis and complete dehiscence of both closures. The patient was then managed with damage control surgery. An atypical gastric resection and enterectomy of the distal ileum were performed and the patient was admitted to the intensive care unit in temporary abdominal closure (laparostomy). The patient failed to improve and died on the same day. Ultimately, the patient's multiple comorbidities, including morbid obesity, malnutrition, and diabetes, contributed to poor tissue healing and the fatal outcome. Gallstone ileus and Bouveret's syndrome are two rare complications of cholecystoduodenal fistulas that have not yet been reported to occur simultaneously. Both intestinal and gastric obstruction makes the surgical approach the first-line treatment.

Endoscopic holmium laser lithotripsy for therapy of Bouveret syndrome

Video 1Video of holmium laser lithotripsy procedure.

Gallstone Ileus: A Rare Cause of Mechanical Bowel Obstruction

A gallstone ileus is a rare cause of mechanical bowel obstruction, accounting for 1% to 4% of all cases. Twenty-five percent of the patients are 65 years of age or older and often present previous significant medical conditions. The authors report the case of an 87-year-old male patient, admitted with the diagnosis of community-acquired pneumonia, who later developed frequent episodes of biliary vomiting, intermittent constipation, and abdominal distension. Abdominal imaging (ultrasound and computed tomography (CT)) showed evidence of a localized inflammatory process in a small bowel loop but excluded vesicular lithiasis. After a failure in the medical approach with antibiotics, an exploratory laparotomy was performed, identifying the intestinal occlusion area, followed by an enterolithotomy at the specific area, and extraction of a 4 cm stone of acellular material. Posteriorly, the patient was treated for three weeks with a carbapenem and physical rehabilitation was promptly initiated with full recovery of his previous status. Gallstone ileus is a very challenging diagnosis and surgery is the treatment of choice. In elderly patients, it is important to promote prompt physical rehabilitation to prevent prolonged bed rest.

An unusual case of mechanical bowel obstruction due to cholecysto-intestinal fistula and impacted gallstone: A case report and literature review

Gallstone ileus is a rare entity and constitutes an uncommon complication of gallstone disease. It is caused by the impaction of a gallstone in the gastrointestinal tract and may cause serious symptoms or even life-threatening complications. It should be part of the differential diagnosis of acute abdomen especially in patients presenting with signs and symptoms of bowel obstruction and known gallstone disease. An early diagnosis is essential, and surgical treatment is the gold standard in order to relieve the obstruction. We present the case of an 84-year-old male patient with gallstone ileus due to cholecysto-intestinal fistula and impacted gallstone at jejunum. He was treated via urgent enterolithotomy, and his post-operative period was uneventful. This report aims to further educate clinical doctors on this rare medical condition which may pose a potentially serious health risk.

Spontaneous resolution of gallstone ileus followed by imaging: A case report and a literature review

Gallstone ileus (GI) is a rare cause of acute abdomen in an emergency setting and a rare complication of cholelithiasis in the elderly, with a female prevalence. Radiologists play a key role in the diagnosis and management of this condition and, with a multimodal approach, diagnostic accuracy usually increases. Spontaneous resolution of GI has previously been reported for stones smaller than 2 cm. Gallstones usually require surgical management; however, in patients with comorbidities and at high risk of surgical complications, a conservative approach may be considered. Herein, we report the case of an 84-year-old woman who came to the emergency department with an acute abdomen pain caused by a GI, with a 2.6 cm gallstone that was revealed on computed tomography and which was followed by diagnostic imaging with spontaneous resolution.

Gallstone Ileus in a Young Patient: A Clinical Case Report and Literature Review

Gallstone ileus is a rare presentation of gallbladder disease. It is mostly encountered in female and elderly patients. It occurs when a stone causes a fistula between the gallbladder and the intestinal lumen. More than half of the patients do not have a history of biliary disease. Surgical intervention is still considered the best treatment option; however, the best choice between one-stage and two-stage surgery is still unknown. We present a gallstone Ileus case in a patient with uncommon epidemiological characteristics: a 28-year-old male Hispanic patient without a gallbladder disease history.

Gallstone Ileus Post-cholecystectomy: A Case Review

Gallstone ileus is an unusual cause of small bowel obstruction, in general, let alone after cholecystectomy. It occurs in patients with chronic calculous cholecystitis and gallstones who develop a cholecystoduodenal fistula over time. The diagnosis is made based on clinical presentation and examination findings and is confirmed with the use of radiological modalities, such as computed tomography (CT) scan, which has been proven to be the most sensitive investigation in diagnosis. Here, we present a case of gallstone ileus that occurred 25 years after laparoscopic cholecystectomy. CT scan on admission showed adhesional small bowel obstruction given the patient's previous abdominal surgery. The patient was managed conservatively as per guidelines for the management of adhesional small bowel obstruction for 72 hours. Obstructive symptoms did not resolve despite all conservative measures, and a gastrografin challenge showed no contrast reaching the colon. Hence, the patient underwent an exploratory laparotomy to manage his ongoing bowel obstruction. Laparotomy revealed gallstone ileus as the cause of obstruction. This case highlights the importance of considering gallstone ileus in the differential diagnosis for patients who present to the emergency department with small bowel obstruction even years after cholecystectomy. Post-cholecystectomy gallstone ileus is very rare with very few cases reported in the literature. This condition poses diagnostic challenges both because of its rarity and because the gallbladder had been previously removed. A high index of suspicion by the surgeon is needed for diagnosis.

Impacted gallstone within a cholecystoduodenal fistula: endoscopic laser lithotripsy to the rescue

Video 1A large, impacted gallstone is treated unsuccessfully with electrohydraulic lithotripsy; however, fragmentation and removal is accomplished using endoscopic laser lithotripsy.

Developments in the Diagnosis and Management of Cholecystoenteric Fistula

Background: Cholecystoenteric fistula (CEF) is a rare complication of cholelithiasis. CEF refers to one or more pathological perforations between the gallbladder and the adjacent gastrointestinal tract, first described by Bartholin in 1645. The aim of this review is to examine the etiology, symptoms, diagnosis, and treatment of CEF.Methods: A literature search was conducted according to a set of criteria in PubMed for historical and current peer-reviewed studies regarding CEF.Results: Clinical manifestations of CEF are always latent. Despite modern imaging studies and diagnostic methods, it is still very difficult to definitively diagnose CEF preoperatively. Instead, CEF is often accidentally discovered in the perioperative period or via intraoperative exploration.Conclusions: Without appropriate preoperative preparation, gastrointestinal injury and intraoperative bleeding often occur. CEF often goes unreported, and its diagnosis and treatment are still controversial. Early diagnosis of CEF is essential for effective treatment and improved outcome.

The Diagnosis and Management of Recurrent Gallstone Ileus: A Case Report

Gallstone ileus is one of the rare and insidious causes of small bowel obstruction, which should always be kept in mind by clinicians, especially when encountering older people with a history of gallstones disease. The high mortality and morbidity rate associated with the condition can be mostly attributed to delayed or misdiagnosis. Imaging modalities, particularly CT scans, play an important role in correct and timely diagnosis. We present the case of a 65-year-old man with a two-year history of colicky biliary pain, who had severe abdominal pain with obstructive symptoms for five days before admission. The diagnosis of gallstone ileus is made using CT scan findings. Enterolithotomy alone was performed three days later. A second, smaller migrated gallstone was also found, which excreted spontaneously. After 20 days, the patient achieved full recovery and was discharged.